Lowered blood pressure targets identify new, uncontrolled hypertensive cases: patient characteristics and implications for services in Thailand.
ABSTRACT: BACKGROUND:According to the new hypertension treatment guidelines blood pressure (BP) readings need to be kept below or equal to 130/80?mmHg in patients aged less than 65?years old. This study shows the change in proportion of identified cases of uncontrolled blood pressure in light of these changes. METHODS:The data was collected from 248 hypertensive patients who had visited an outpatient clinic at the Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Thailand. Patients were classified into three groups: The 3 groups were: 1) controlled BP group (BP is 130/80?mmHg or lower); 2) newly identified uncontrolled group (BP between 130/80?mmHg and 140/90?mmHg) and 3) existing uncontrolled group (BP higher than 140/90?mmHg). Health behaviors, past history related to hypertensive disease and current pharmacological treatments were compared. RESULTS:Of the total 248 patients, 56% were female and the mean age was 58.8 (sd 5.99) years old. Following application of the new guidelines, the group designated as uncontrolled increased from 21.7 to 74.2%, an additional 52.4% due to new BP targets. Higher BMI was associated with uncontrolled HT (p?=?0.043). While the average number of medication taken was similar across the three groups, it was poor medication adherence (p?
Project description:BACKGROUND:Little is known about age-specific target blood pressure (BP) in hypertensive patients with diabetes mellitus (DM). The aim of this study was to determine the BP level at the lowest cardiovascular risk of hypertensive patients with DM according to age. METHODS:Using the Korean National Health Insurance Service database, we analyzed patients without cardiovascular disease diagnosed with both hypertension and DM from January 2002 to December 2011. Primary end-point was composite cardiovascular events including cardiovascular death, myocardial infarction and stroke. RESULTS:Of 241,148 study patients, 35,396 had cardiovascular events during a median follow-up period of 10 years. At the age of?<?70 years, the risk of cardiovascular events was lower in patients with BP?<?120/70 mmHg than in those with BP 130-139/80-89 mmHg. At the age of???70, however, there were no significant differences in the risk of cardiovascular events between patients with BP 130-139/80-89 mmHg and BP?<?120/70 mmHg. The risk of cardiovascular events was similar between patients with BP 130-139/80-89 mmHg and BP 120-129/70-79 mmHg, and it was significantly higher in those with BP???140/90 mmHg than in those with BP 130-139/80-89 mmHg at all ages. CONCLUSIONS:In a cohort of hypertensive patients who had DM but no history of cardiovascular disease, lower BP was associated with lower risk of cardiovascular events especially at the age of?<?70. However, low BP?<?130-139/80-89 mmHg was not associated with decreased cardiovascular risk, it may be better to keep the BP of 130-139/80-89 mmHg at the age of???70.
Project description:Aims:The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline on high blood pressure (BP) lowered the threshold defining hypertension and BP target in high-risk patients to 130/80?mmHg. Patients with coronary artery disease and systolic BP 130-139?mmHg or diastolic BP 80-89?mmHg should now receive medication to achieve this target. We aimed to investigate the relationship between BP and cardiovascular events in 'real-life' patients with coronary artery disease considered as having normal BP until the recent guideline. Methods and results:Data from 5956 patients with stable coronary artery disease, no history of hypertension or heart failure, and average BP <140/90?mmHg, enrolled in the CLARIFY registry (November 2009 to June 2010), were analysed. In a multivariable-adjusted Cox proportional hazards model, after a median follow-up of 5.0?years, diastolic BP 80-89?mmHg, but not systolic BP 130-139?mmHg, was associated with increased risk of the primary endpoint, a composite of cardiovascular death, myocardial infarction, or stroke (hazard ratio 2.15, 95% confidence interval 1.22-3.81 vs. 70-79?mmHg and 1.12, 0.64-1.97 vs. 120-129?mmHg). No significant increase in risk for the primary endpoint was observed for systolic BP <120?mmHg or diastolic BP <70?mmHg. Conclusion:In patients with stable coronary artery disease defined as having normal BP according to the 140/90?mmHg threshold, diastolic BP 80-89?mmHg was associated with increased cardiovascular risk, whereas systolic BP 130-139?mmHg was not, supporting the lower diastolic but not the lower systolic BP hypertension-defining threshold and treatment target in coronary artery disease. ClinicalTrials identifier:ISRCTN43070564.
Project description:BACKGROUND:This study aimed to test the feasibility and titration methods used to achieve specific blood pressure (BP) control targets in hypertensive patients of rural China. METHODS:A randomized, controlled, open-label trial was conducted in Rongcheng, China. We enrolled 105 hypertensive participants aged over 60?years, and who had no history of stroke or cardiovascular disease. The patients were randomly assigned to one of three systolic-BP target groups: standard: 140 to?<?150?mmHg; moderately intensive: 130 to?<?140?mmHg; and intensive: <?130?mmHg. The patients were followed for 6?months. DISCUSSION:The optimal target for systolic blood pressure (SBP) lowering is still uncertain worldwide and such information is critically needed, especially in China. However, in China the rates of awareness, treatment and control are only 46.9%, 40.7%, and 15.3%, respectively. It is challenging to achieve BP control in the real world and it is very important to develop population-specific BP-control protocols that fully consider the population's characteristics, such as age, sex, socio-economic status, compliance with medication, education level, and lifestyle. This randomized trial showed the feasibility and safety of the titration protocol to achieve desirable SBP targets (<?150, <?140, and?<?130?mmHg) in a sample of rural, Chinese hypertensive patients. The three BP target groups had similar baseline characteristics. After 6?months of treatment, the mean SBP measured at an office visit was 137.2?mmHg, 131.1?mmHg, and 124.2?mmHg, respectively, in the three groups. Home BP and central aortic BP measurements were also obtained. At 6?months, home BP measurements (2?h after drug administration) showed a mean SBP of 130.9?mmHg in the standard group, 124.9?mmHg in the moderately intensive group, and 119.7?mmHg in the intensive group. No serious adverse events were recorded over the 6-month study period. Rates of adverse events, including dry cough, palpitations, and arthralgia, were low and showed no significant differences between the three groups. This trial provided real-world experience and laid the foundation for a future, large-scale, BP target study. TRIAL REGISTRATION:Feasibility Study of the Intensive Systolic Blood Pressure Control; ClinicalTrials.gov, ID: NCT02817503. Registered retrospectively on 29 June 2016.
Project description:Elevated blood pressure (BP) is a significant burden worldwide, leading to high cardio-cerebro-reno-vascular morbidity and mortality. For the second year of the May Measurement Month (MMM) campaign in Indonesia in 2018, we recruited 174 sites in 31 out of 34 provinces in Indonesia and screened through convenience sampling in public areas and rural primary health centres. Hypertension was defined as systolic BP ?140?mmHg or diastolic BP ?90?mmHg, or both, or on the basis of receiving antihypertensive medication. Blood pressure was measured three times followed the standard global MMM protocol, multiple imputation was used to estimate the mean of the 2nd and 3rd BP readings if these were not recorded. A total of 91 222 individuals were screened, and after multiple imputations, 27 331 (30.0%) had hypertension. Of individuals not receiving antihypertensive medication, 14 367 (18.4%) were hypertensive. Among the 47.4% of hypertensive individuals on antihypertensive medication, 10 106 (78.0%) had uncontrolled BP. MMM17 and MMM18 were still the most extensive standardized screening campaigns for BP measurement in Indonesia. Compared to the previous study, the proportion with uncontrolled BP on medication was significantly higher and provided the substantial challenges in managing hypertension in the rural community.
Project description:This is a prespecified subgroup analysis in Hispanic and non-Hispanic patients of a study that evaluated blood pressure (BP) control with fixed-dose amlodipine/olmesartan medoxomil (AML/OM)-based therapy in patients whose condition was uncontrolled on prior monotherapy.In this prospective, open-label, dose-titration study, patients with uncontrolled BP after at least 1 month of antihypertensive monotherapy were switched to fixed-dose AML/OM 5/20 mg. Patients were uptitrated to AML/OM 5/40 and 10/40 mg, with uptitration to AML/OM + hydrochlorothiazide 10/40 + 12.5 mg and 10/40 + 25 mg to achieve target BP. The primary efficacy endpoint was the cumulative proportion of patients achieving seated cuff systolic BP (SeSBP) less than 140 mmHg (<130 mmHg in patients with diabetes mellitus) at 12 weeks. Secondary endpoints included SeBP goal rates, ambulatory BP (ABP) target rates, and mean change from baseline in seated cuff BP (SeBP) and ABP at weeks 12 and 20.Mean baseline BP was similar in Hispanics (153.6/92.8 mmHg; n = 105) and non-Hispanics (153.7/91.8 mmHg; n = 894). At 12 weeks, 72.0% of Hispanics and 76.3% of non-Hispanics achieved the primary endpoint. At week 12, goal rates for cumulative SeBP (<140/90 mmHg or <130/80 mmHg in patients with diabetes) were 69.0% and 71.5% in Hispanic and non-Hispanic patients, respectively. Mean change in SeBP in Hispanics ranged from -15.3/-7.3 mmHg for AML/OM 5/20 mg to -23.2/-13.8 mmHg for AML/OM 10/40 mg + hydrochlorothiazide 25 mg, and in non-Hispanics from -14.1/-7.8 mmHg to -25.4/-13.7 mmHg (all p < 0.0001 versus baseline). A majority of patients achieved mean 24 h, daytime, and nighttime ABP targets in both subgroups. Greater proportions of Hispanics achieved ABP targets versus non-Hispanics at week 12; however, this trend was reversed at week 20. Treatment was well tolerated.Switching to a fixed-dose combination of AML/OM ± hydrochlorothiazide provided significant BP lowering and effectively controlled BP in a large proportion of Hispanic and non-Hispanic patients with hypertension uncontrolled on previous monotherapy.
Project description:BACKGROUND:Resistant hypertension is independently associated with an increased risk of death in the general hypertensive population. We assessed whether resistant hypertension is an independent predictor of all-cause mortality in individuals with type 2 diabetes from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study. METHODS:On 31 October 2015, vital status information was retrieved for 15,656 of the 15,773 participants enrolled in 2006-2008. Based on baseline blood pressure (BP) values and treatment, participants were categorized as normotensive, untreated hypertensive, controlled hypertensive (i.e., on-target with <?3 drugs), uncontrolled hypertensive (i.e., not on-target with 1-2 drugs), or resistant hypertensive (i.e., uncontrolled with >?3 drugs or controlled with >?4 drugs). Kaplan-Meier and Cox proportional hazards regression analyses were used to assess the association with all-cause mortality. RESULTS:Using the 130/80?mmHg targets for categorization, crude mortality rates and Kaplan-Meier estimates were highest among resistant hypertension participants, especially those with controlled resistant hypertension. As compared with resistant hypertension, risk for all-cause mortality was significantly lower for all the other groups, including individuals with controlled hypertension (hazard ratio 0.81 [95% confidence interval 0.74-0.89], P?<?0.0001), but became progressively similar between resistant and controlled hypertension after adjustment for cardiovascular risk factors and complications/comorbidities. Also when compared with controlled resistant hypertension, mortality risk was significantly lower for all the other groups, including controlled hypertension, even after adjusting for cardiovascular risk factors (0.77 [0.63-0.95], P?=?0.012), but not for complications/comorbidities (0.88 [0.72-1.08], P?=?0.216). BP was well below target in the controlled hypertensive groups (resistant and non-resistant) and values <?120/70?mmHg were associated with an increased mortality risk. Results changed only partly when using the 140/90?mmHg targets for categorization. CONCLUSIONS:In the RIACE cohort, at variance with the general hypertensive population, resistant hypertension did not predict death beyond target organ damage. Our findings may be explained by the high mortality risk conferred by type 2 diabetes and the low BP values observed in controlled hypertensive patients, which may mask risk associated with resistant hypertension. Less stringent BP goals may be preferable in high-risk patients with type 2 diabetes. TRIAL REGISTRATION:ClinicalTrials.gov, NCT00715481 , retrospectively registered 15 July, 2008.
Project description:Hypertension is a public health problem and a major risk factor for cardiovascular disease. The purpose of this study is to compare the effectiveness of a multidisciplinary program based on group and individual care versus group-only care, to promote blood pressure control in hypertensive patients in primary health care.Randomized controlled clinical trial. The study was conducted within the primary health care, in two units of the Family Health Strategy, covering 11,000 individuals, in Porto Alegre, Brazil. Two hundred and 56 patients, older than 40 years old and with uncontrolled hypertension, systolic blood pressure (BP) ?140 mmHg and/or diastolic BP ?90 mmHg or ?130 mmHg and/or diastolic BP ?80 mmHg for individuals with diabetes. Eligible patients were randomly assigned to a health care program aiming for blood pressure control, with the multidisciplinary program group or with the multidisciplinary program plus personalized care group. Primary outcome measures were reduction in systolic BP from baseline to 6 months. Secondary measures included proportion of patients with systolic or diastolic BP controlled. Student t test, Pearson's chi-squared test, Fisher's exact test, Mann-Whitney U test, Wilcoxon signed-ranks test and generalized estimating equation (GEE) model were used in the analysis.The baseline characteristics of participants were similar between groups. After 6 months of follow-up, systolic BP decreased markedly in both groups (? - 11.8 mmHg [SD, 20.2] in the multidisciplinary program group and ? - 12.9 mmHg [SD, 19.2] in the personalized care group; p?<?0.001). Similarly, we noted a significant change in diastolic BP over time in both groups (? - 8.1 mmHg [SD, 10.8] in the multidisciplinary program group and ? - 7.0 mmHg [SD, 11.5] in the personalized care group; p?<?0.001).The study demonstrates similar effectiveness of a group intervention in comparison to a personalized education program in hypertension patients to achieve BP control. These findings indicate that the intervention can be for all hypertensive patients assisted in primary health care.ClinicalTrials.gov Identifier NCT01696318 (May 2013).
Project description:Hypertension and obesity are the most important modifiable risk factors for cardiovascular diseases, but their association is not well characterized in Africa. We investigated regional patterns and association of obesity with hypertension among 30 044 continental Africans. We harmonized data on hypertension (defined as previous diagnosis/use of antihypertensive drugs or blood pressure [BP]?140/90 mmHg/BP?130/80 mmHg) and obesity from 30 044 individuals in the Cardiovascular H3Africa Innovation Resource across 13 African countries. We analyzed data from population-based controls and the Entire Harmonized Dataset. Age-adjusted and crude proportions of hypertension were compared regionally, across sex, and between hypertension definitions. Logit generalized estimating equation was used to determine the independent association of obesity with hypertension (P value <5%). Participants were 56% women; with mean age 48.5±12.0 years. Crude proportions of hypertension (at BP?140/90 mmHg) were 47.9% (95% CI, 47.4-48.5) for Entire Harmonized Dataset and 42.0% (41.1-42.7) for population-based controls and were significantly higher for the 130/80 mm Hg threshold at 59.3% (58.7-59.9) in population-based controls. The age-adjusted proportion of hypertension at BP?140/90 mmHg was the highest among men (33.8% [32.1-35.6]), in western Africa (34.7% [33.3-36.2]), and in obese individuals (43.6%; 40.3-47.2). Obesity was independently associated with hypertension in population-based controls (adjusted odds ratio, 2.5 [2.3-2.7]) and odds of hypertension in obesity increased with increasing age from 2.0 (1.7-2.3) in younger age to 8.8 (7.4-10.3) in older age. Hypertension is common across multiple countries in Africa with 11.9% to 51.7% having BP?140/90 mmHg and 39.5% to 69.4% with BP?130/80 mmHg. Obese Africans were more than twice as likely to be hypertensive and the odds increased with increasing age.
Project description:Previous epidemiological studies have suggested that uric acid is an independent risk factor for incident hypertension, whereas few studies have evaluated the effect of hyperuricemia on blood pressure control in hypertensive patients. We investigated whether hyperuricemia predicts uncontrolled hypertension through a large-scale prospective cohort study with hypertensive patients treated with fimasartan in the Republic of Korea (the Kanarb-Metabolic Syndrome study).Of the 10,601 hypertensive patients who were recruited from 582 private clinics and 11 university hospitals at baseline, 7725 completed the follow-up after 3 months of fimasartan medication, and 6506 were included in the analysis after excluding those with missing values. We estimated the risk of uncontrolled hypertension after 3 months (?130/80 mm Hg in those with diabetes or chronic renal failure and ?140/90 mm Hg in the remaining patients) related with baseline hyperuricemia (serum uric acid ?7?mg/dL in males ?6?mg/dL in females) using multiple logistic regression models.Hyperuricemia increased the risk of uncontrolled hypertension after 3 months of fimasartan medication (odds ratio, 1.247; 95% confidence interval, 1.063-1.462). Males in the highest quartile of uric acid level were at a 1.322 (95% confidence interval, 1.053-1.660) times higher risk of uncontrolled hypertension in reference to the lowest quartile; the same analyses in females were not significant. Patients without metabolic syndrome had significantly higher odds of uncontrolled hypertension with hyperuricemia (odds ratio, 1.328; 95% confidence interval, 1.007-1.751).Hyperuricemia predicted uncontrolled hypertension even after 3 months of fimasartan treatment in hypertensive patients.
Project description:Masked uncontrolled hypertension (MUCH) in treated hypertensive patients is defined as controlled automated office blood pressure (BP; <135/85 mm?Hg) in-clinic but uncontrolled out-of-clinic BP by ambulatory BP monitoring (awake [daytime] readings ?135/85 mm?Hg or 24-hour readings ?130/80 mm?Hg). To determine whether MUCH is attributable to antihypertensive medication nonadherence. One hundred eighty-four enrolled patients were confirmed to have controlled office BP; of these, 167 patients were with adequate 24-hour ambulatory BP recordings. Of 167 patients, 86 were controlled by in-clinic BP assessment but had uncontrolled ambulatory awake BP, indicative of MUCH. The remaining 81 had controlled in-clinic and ambulatory awake BP, consistent with true controlled hypertension. After exclusion of 9 patients with missing 24-hour urine collections, antihypertensive medication adherence was determined based on the detection of urinary drugs or drug metabolites by high-performance liquid chromatography-tandem mass spectrometry. Of the 81 patients with MUCH, 69 (85.2%) were fully adherent and 12 (14.8%) were partially adherent (fewer medications detected than prescribed). Of the 77 patients with true controlled hypertension, 69 (89.6%) were fully adherent with prescribed antihypertensive medications and 8 (10.4%) were partially adherent. None of the patients in either group were fully nonadherent. There was no statistically significant difference in complete or partial adherence between the MUCH and true controlled groups (P=0.403). Measurement of urinary drug and drug metabolite levels demonstrates a similarly high level of antihypertensive medication adherence in both MUCH and truly controlled hypertensive patients. These findings indicate that MUCH is not attributable to antihypertensive medication nonadherence.